Campaspe PCP Getting started with Care Planning Campaspe Primary Care Partnership

Objectives To demystify Care Planning To increase understanding of care planning and where it fits in practice To introduce the types of care plans To define the role of a key worker or care coordinator

Context Service Coordination  Statewide approach  Places consumers at the centre of service delivery  4 operational elements of SC are Initial Contact; Initial Needs Identification; Assessment and Care Planning  Care Planning key work area of the Service Coordination Steering Committee and PCP Strategic Plan

Operational elements of Service Coordination

Resources Victorian Service Coordination Practice Manual – 2009 (update due in July 2012) Good Practice Guide 2009 Continuous Improvement Framework Service Coordination Tool Templates user guide Local Key Worker Roles & Responsibilities document

Websites

What is Care Planning? Dynamic process Involves negotiation, decision making and goal setting Relies on good communication between consumer, service providers and GPs

Care Planning Objectives Planned, evidence based and person centred Actively engage consumers in planning Consider social, emotional and health issues Based on needs goals and actions Includes education and self management interventions Monitor and review progress Underpinned by good communication Meets legislative requirements

Benefits of Care Planning Assist consumers to set goals Encourages consumer involvement and self- management Manages and monitors long term care Provides a checklist Documents information e.g. action plans Encourages team approaches Is proactive rather than reactive Increase consumer awareness of services

Person-Centred Practice Principles Partnership approach Holistic Open communication Respect and privacy Inclusive of family and carers Supports self-management and responsibility Participation in decision making Supports autonomy

Types of Care Plans Service Specific Intra-agency Inter-agency

Service Specific Care Plan This is a care plan developed by a single service The consumer has one or more issues that can be managed with support of a single program area District Nursing treatment plan Physiotherapy treatment plan GP Asthma management plan

Intra-agency care plan Require multiple services from a single organisation Individual service specific care plans Overarching intra agency care plan Requires key worker; eg.  Diabetes Services care plan  HACC services plan

Inter-agency Care Plan Consumer has range of chronic, complex &/or multiple issues Involves separate agencies 3 or more ongoing service providers Key worker  Complex care plan  CAPS case management care plan  GP team care arrangements  Transitional care plan

Elements of a Care Plan 1.Date 2.Participants 3.Consumer stated issues 4.Consumer stated goals 5.Agreed actions & service responsible 6.Timeframes 7.Review dates 8.Consumer acknowledgement 9.Actual review date

SCTT Care Coordination Plan

Issues to consider Consumer stated or agreed issues Do all consumers need all the care plans Who is the key worker

Role of the Key Worker Engagement and empowerment Consolidate information Service system knowledge Documentation of plan and monitoring Communication and liaison Facilitating case conferencing Provision of feedback

Local documentation – Support guide Campaspe Care Planning Key Worker Roles and Responsibilities document provides info on; o What is a care plan & definitions o What is a key worker o Steps in developing a CP o Roles and responsibilities of the key worker o References to tools/forms to use

Goal Setting Linked to problem/issue Written in positive Written in the consumers words SMART Can be maintenance goals Should not be interventions

Setting Goals and Action Planning Something the consumer wants to do Achievable Action specific Answer what, how much, when, how often? Confidence level 7 or more

Goal setting – practice example Overall aim to lose weight. Goal Specific- aim to help lose weight by increasing the amount of walking Measurable- walk for 30 minutes Achievable- confident that could manage to walk for that long Realistic- need to take the dog for a walk so will be the motivation I need. Timely- will walk 3 times per week in the afternoon

Conclusion Care planning is part of service coordination Each service will have specific involvement with care planning Know what your role is? Be familiar with the documentation

Final point It may seem time consuming but the aim of service coordination is to ensure the consumer receives  the right help  at the right time  by the right person BE CONFIDENT IN YOUR ROLE IN THE CONSUMERS JOURNEY